Tien-Yu Shieh

Intercountry prevalences and practices of betel-quid use in south, southeast and eastern asia regions and associated oral preneoplastic disorders: An international collaborative study by asian betel-quid consortium of south and east Asia

Health risks stemming from betel‐quid (BQ) chewing are frequently overlooked by people. Updated epidemiological data on the increased BQ use among Asian populations using comparable data collection methods have not been widely available. To investigate the prevalence, patterns of practice and associated types of oral preneoplastic disorders, an intercountry Asian Betel‐quid Consortium study (the ABC study) was conducted for Taiwan, Mainland China, Malaysia, Indonesia, Nepal and Sri Lanka. A random sample of 8,922 subjects was recruited, and the data were analyzed using survey‐data modules adjusted for the complex survey design. Chewing rates among men (10.7–43.6%) were significantly higher than women (1.8–34.9%) in Taiwan, Mainland China, Nepal and Sri Lanka, while womens rates (29.5–46.8%) were higher than that for men (9.8–12.0%) in Malaysia and Indonesia. An emerging, higher proportion of new‐users were identified for Hunan in Mainland China (11.1–24.7%), where Hunan chewers have the unique practice of using the dried husk of areca fruit rather than the solid nut universally used by others. Men in the Eastern and South Asian study communities were deemed likely to combine chewing with smoking and drinking (5.6–13.6%). Indonesian women who chewed BQ exhibited the highest prevalence of oral lichen planus, oral submucous fibrosis and oral leukoplakia (9.1–17.3%). Lower schooling, alcohol drinking and tobacco smoking were identified as being associated with BQ chewing. In conclusion, the ABC study reveals the significant cultural and demographic differences contributing to practice patterns of BQ usage and the great health risks that such practices pose in the Asian region.

miRNA-491-5p and GIT1 Serve as Modulators and Biomarkers for Oral Squamous Cell Carcinoma Invasion and Metastasis

MicroRNAs offer tools to identify and treat invasive cancers. Using highly invasive isogenic oral squamous cell carcinoma (OSCC) cells, established using in vitro and in vivo selection protocols from poorly invasive parental cell populations, we used microarray expression analysis to identify a relative and specific decrease in miR-491-5p in invasive cells. Lower expression of miR-491-5p correlated with poor overall survival of patients with OSCCs. miR-491-5p overexpression in invasive OSCC cells suppressed their migratory behavior in vitro and lung metastatic behavior in vivo. We defined the G-protein-coupled receptor kinase-interacting protein 1 (GIT1)-as a direct target gene for miR-491-5p control. GIT1 overexpression was sufficient to rescue miR-491-5p-mediated inhibition of migration/invasion and lung metastasis. Conversely, GIT1 silencing phenocopied the ability of miR-491-5p to inhibit migration/invasion and metastasis of OSCC cells. Mechanistic investigations indicated that miR-491-5p overexpression or GIT1 attenuation reduced focal adhesions, with a concurrent decrease in steady-state levels of paxillin, phospho-paxillin, phospho-FAK, EGF/EGFR-mediated extracellular signal-regulated kinase (ERK1/2) activation, and MMP2/9 levels and activities. In clinical specimens of OSCCs, GIT1 levels were elevated relative to paired normal tissues and were correlated with lymph node metastasis, with expression levels of miR-491-5p and GIT1 correlated inversely in OSCCs, where they informed tumor grade. Together, our findings identify a functional axis for OSCC invasion that suggests miR-491-5p and GIT1 as biomarkers for prognosis in this cancer.

Malignant transformation of oral potentially malignant disorders in males: a retrospective cohort study.

BackgroundOral squamous cell carcinoma could be preceded by clinically evident oral potentially malignant disorders (OPMDs). Transformation of OPMDs to cancer has been studied in several population groups. It is difficult to undertake comparisons across populations due to variations in the methods of computation of malignancy rates among different studies. The aim of our study was to estimate the rate of malignant transformation of OPMDs taking into account the duration of follow-up and to identify the significant factors indicative of malignant potential.MethodsA total of 148 male patients with OPMDs were included. They were selected among all consecutive subjects registered at the maxillofacial clinic at a medical hospital in Kaohsiung, Taiwan. The mean follow up period was 37.8 months.ResultsThe malignant transformation rate was highest in subjects diagnosed with oral epithelial dysplasia. In this group the transformation rate was 7.62 per 100 persons-year. The rate in the group with verrucous hyperplasia (VH) was 5.21 per 100 persons-year, and in those with hyperkeratosis or epithelial hyperplasia was 3.26 per 100 persons-year. The anatomical site of OPMDs was the only statistically significant variable associated with malignancy. The hazard rate ratio (HRR) was 2.41 times for tongue lesions when compared with buccal lesions.ConclusionThe reported discrepancies of malignant transformation of OPMDs involve the follow-up time to cancer development and hence it is preferable to use a time-to-event estimation for comparisons. We found that malignant transformation of OPMDs involving the tongue was significantly higher than in other anatomical subsites after adjusting for the clinicopathological type or lifestyle factors at diagnosis.

Up-regulation of Inflammatory Signalings by Areca Nut Extract and Role of Cyclooxygenase-2 −1195G>A Polymorphism Reveal Risk of Oral Cancer

Because the mRNA expression of cyclooxygenase-2 (COX-2) is up-regulated by arecoline in human gingival fibroblasts, as shown in our previous study, we further investigated the mRNA expression level of COX-2 and its upstream effectors in three oral epithelial carcinoma cell lines (KB, SAS, and Ca9-22) by using areca nut extract (ANE) and saliva-reacted ANE (sANE). A case-control study of 377 oral squamous cell carcinoma (OSCC) patients and 442 controls was conducted to evaluate the gene-environment interaction between COX-2 promoter polymorphisms and substance use of alcohol, betel quid, and cigarettes (ABC) in risk of OSCC. The heterogeneous characteristics of the oral site and the COX-2 -1195G>A polymorphism in these cell lines showed diverse inflammatory response (KB>>Ca9-22>SAS) after 24-hour ANE/sANE treatments, and the COX-2 up-regulation might be mostly elicited from alternative nuclear factor-kappaB activation. In the case-control study, betel chewing [adjusted odds ratios (aOR), 42.2] posed a much higher risk of OSCC than alcohol drinking and cigarette smoking (aORs, 2.4 and 1.8, respectively), whereas the COX-2 -1195A/A homozygote presented a potential genetic risk (OR, 1.55). The strongest joint effect for OSCC was seen in betel chewers with -1195A/A homozygote (aOR, 79.44). In the non-betel chewing group, the -1195A/G and A/A genotypes together with the combined use of alcohol and cigarettes increased risk to 15.1-fold and 32.1-fold, respectively, compared with the G/G genotype without substance use. Taken together, these findings illustrate a valuable insight into the potential role of the COX-2 promoter region in contributing to the development of betel-related OSCC, including ANE/sANE-induced transcriptional effects and enhanced joint effects of COX-2 -1195A allele with substance use of ABC.

Augmented mRNA expression of tissue inhibitor of metalloproteinase-1 in buccal mucosal fibroblasts by arecoline and safrole as a possible pathogenesis for oral submucous fibrosis

Oral submucous fibrosis (OSF) is an oral precancerous condition, and is associated with betel quid (BQ) chewing habits. It is a disorder of excessive deposition of collagen in the connective tissues that results from disruption in the regulation of the equilibrium between matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs). Elevated TIMP-1 protein has been thought to be associated with oral fibrosis, however whether TIMP-1 expression in OSF is modulated at the transcriptional level is still unknown. The present study used arecoline, arecaidine and safrole, which are thought to be major toxic ingredients in BQ, as candidates to explore the role of TIMP-1 expression in OSF pathogenesis. Fresh tissue biopsies of oral mucosa from 20 OSF males were included in this study, and fibroblasts were cultured from one OSF buccal mucosa and one normal buccal mucosa of the same OSF patient. To quantify the TIMP-1 expression, enzyme-linked immunosorbent assay (ELISA) was used in the present study. The results indicated that OSF fibroblasts produced more TIMP-1 protein (569.2+/-79.5 ng/ml) than normal fibroblasts (303.0+/-59.3 ng/ml) from the same patients, and the mRNA expression of TIMP-1 in OSF fibroblasts was higher (1.76 fold) than normal fibroblasts of the same patients. Arecoline and safrole significantly elevated TIMP-1 protein and mRNA expression. We concluded that increased mRNA expression of TIMP-1 in buccal mucosal fibroblasts by arecoline and safrole is a possible pathogenesis for oral submucous fibrosis.

Isolation and characterization of human dental pulp stem/stromal cells from nonextracted crown-fractured teeth requiring root canal therapy.

INTRODUCTION Human dental pulp stem/stromal cells (hDPSCs) in adults are primarily derived from the pulp tissues of permanent third molar teeth in existing literatures, whereas no reports exist, to our knowledge, on deriving hDPSCs from a tooth without the need for surgical procedure. The aim of this study was to raise a novel idea to source hDPSCs from complicated crown-fractured teeth requiring root canal therapy. METHODS hDPSCs were harvested from the pulp tissues for two complicated crown-fractured teeth requiring root canal therapy, retaining the teeth for subsequent prosthodontic rehabilitation, in a 41-year-old woman who had suffered a motorcycle accident. Pulp tissue from the left lower deciduous canine of a healthy 10-year-old boy (the positive control) was also removed because of high mobility and cultured for hDPSCs. RESULTS The hDPSCs derived from the two complicated crown-fractured teeth and the deciduous tooth were able to differentiate into adipogenic, chondrogenic, and osteogenic lineages and also expressed stem cells markers and differentiation markers, which indicated their stem cell origin and differentiation capability. In addition, hDPSCs from both the complicated crown-fractured teeth and the deciduous tooth showed high expression for bone marrow stem cell markers including CD29, CD90, and CD105 and exhibited very low expression of markers specific for hematopoietic cells such as CD14, CD34, and CD45. CONCLUSIONS This report describes the successful isolation and characterization of hDPSCs from the pulp tissue of complicated crown-fractured teeth without tooth extraction. Therefore, pulp exposed in complicated crown-fractured teeth might represent a valuable source of personal hDPSCs.

Population Burden of Betel Quid Abuse and Its Relation to Oral Premalignant Disorders in South, Southeast, and East Asia: An Asian Betel-Quid Consortium Study

OBJECTIVES We investigated the population burden of betel quid abuse and its related impact on oral premalignant disorders (OPDs) in South, Southeast, and East Asia. METHODS The Asian Betel-Quid Consortium conducted a multistage sampling of 8922 representative participants from Taiwan, Mainland China, Malaysia, Indonesia, Nepal, and Sri Lanka. Participants received an interviewer-administered survey and were examined for oral mucosal disorders. RESULTS The prevalence of betel quid abuse was 0.8% to 46.3% across 6 Asian populations. The abuse frequency was over 40.5% for current chewers, with the highest proportion in Nepalese and Southeast Asian chewers (76.9%-99.6%). Tobacco-added betel quid conferred higher abuse rates (74.4%-99.6%) among Malaysian, Indonesian, and Sri Lankan men than did tobacco-free betel quid (21.8%-89.1%). Gender, lower education level, younger age at chewing initiation, and clustering of familial betel quid use significantly contributed to higher abuse rates. Indonesian betel quid abusers showed the highest prevalence of OPDs and had a greater risk of OPDs than did nonabusers. CONCLUSIONS Betel quid abuse is high in regions of Asia where it is customarily practiced, and such abuse correlates highly with OPDs. By recognizing abuse-associated factors, health policies and preventive frameworks can be effectively constructed to combat these oral preneoplasms.

Prognostic factors associated with the survival of oral and pharyngeal carcinoma in Taiwan

BackgroundIn Taiwan, a distinct ethnic group variation in incidence and mortality rates has been suggested for most carcinomas. Our aim is to identify the role of prognostic factors associated with the survival of oral and pharyngeal carcinoma in Taiwan.MethodsTaiwan Cancer Registry records of 9039 subjects diagnosed with oral and pharyngeal carcinoma were analyzed. The population was divided into three ethnic groups by residence, which were Taiwanese aborigines, Hakka and Hokkien communities. Five-year survival rates were estimated by Kaplan-Meier methods. Ethnic curves differed significantly by log-rank test; therefore separate models for Taiwanese aborigines, Hakka and Hokkien were carried out. The Cox multivariate proportional hazards model was used to examine the role of prognostic factors on ethnic survival.ResultsThe five-year survival rates of oral and pharyngeal carcinoma were significantly poorer for Hokkien community (53.9%) and Taiwanese aborigines community (58.1%) compared with Hakka community (60.5%). The adjusted hazard ratio of Taiwanese aborigines versus Hakka was 1.07 (95%CI, 0.86–1.33) for oral and pharyngeal carcinoma mortality, and 1.16 (95%CI, 1.01–1.33) for Hokkien versus Hakka. Males had significantly poor prognosis than females. Subjects with tongue and/or mouth carcinoma presented the worst prognosis, whereas lip carcinoma had the best prognosis. Subjects with verrucous carcinoma had better survival than squamous cell carcinoma. Prognosis was the worst in elderly subjects, and subjects who underwent surgery had the highest survival rate.ConclusionOur study presented that predictive variables in oral and pharyngeal carcinoma survival have been: ethnic groups, period of diagnosis, gender, diagnostic age, anatomic site, morphologic type, and therapy.

The neoplastic impact of tobacco-free betel-quid on the histological type and the anatomical site of aerodigestive tract cancers

Little is known about any consequences of swallowing tobacco‐free betel‐quid (TF‐BQ) juice/remnants following chewing and its carcinogenic impact on the upper aerodigestive tract (UADT) to gastrointestinal tract (GIT). We investigated the neoplastic impact of TF‐BQ on different anatomical locations along UADT and GIT, and differences according to their histological categories. We conducted a multicenter case–control study examining patients with 2,163 pathology‐proven UADT and GIT cancers, comparing them with 2,250 control subjects. Generalized additive models, piecewise regression and polytomous logistic models were applied to identify possible dose‐dependent structures and cancer risks. Contrary to nonsignificant GIT‐adenocarcinoma risk (aOR = 0.9), TF‐BQ users experienced a 1.7‐ to 16.2‐fold higher risk of UADT‐squamous cell carcinomas than nonusers, with the peak risk discovered in oral neoplasms. We separately observed a curvilinear and linear TF‐BQ dose‐risk relationship in oral/pharyngeal/esophageal and laryngeal cancers. Chewers of betel inflorescence were generally at a greater UADT cancer risk. A higher first‐piecewise increased risk of esophageal cancer was recognized among areca‐fluid swallowers than among nonswallowers (continuous aOR = 1.12 vs. 1.03). TF‐BQ use accounted for 66.1–78.7% and 17.8–33.2% of the cases of oral/pharyngeal and esophageal/laryngeal cancers, respectively. However, a reduction from heavy TF‐BQ consumption to low‐to‐moderate consumption only reduced 11.3–34.6% of etiologic fraction of oral/pharyngeal cancers. Alcohol supra‐additively modified the risk of TF‐BQ in determining the development of oral, pharyngeal and esophageal cancers. In conclusion, the interplay of TF‐BQ and alcohol/tobacco use, combined with how chewing habit is practiced, influences carcinogenic consequences on anatomically diverse sites of UADT and GIT cancers, and histologically different types.

Importance of Patient’s Cooperation in Surgical Treatment for Oral Submucous Fibrosis

PURPOSE The aim of this study was to investigate the results of surgical treatment for oral submucous fibrosis (OSF) in patients who did or did not cooperate with the rehabilitation regimen. PATIENTS AND METHODS There were 54 patients who had surgical treatment of trismus caused by OSF. Split-thickness skin grafts were used to repair surgical defects after surgery on the fibrous bands. According to postoperative collaboration in the rehabilitation regimen, patients were defined as non-cooperative patients (group I) and cooperative patients (group II). Group I (n = 28) and group II (n = 26) were analyzed separately for changes in preoperative, intraoperative, and postoperative interincisal distances (ID) for at least 6 months after surgery. RESULTS The mean preoperative ID was 18.9 mm (range, 8 to 25 mm) in group I and 18 mm (range, 7 to 25 mm) in group II. The intraoperative ID increased to an average of 39 mm in group I and 38.5 mm in group II. The mean final follow-up ID was 22 mm in group I and 36.1 mm in group II. When evaluating the changes of ID, only a statistically significant difference was found at final visit between groups. CONCLUSIONS In our study, we found the patients cooperation is the primary requirement for success in the treatment of OSF.